What are the criteria for diagnosing left ventricular hypertrophy (LVH) on an electrocardiogram (ECG)?

ECG Criteria for Left Ventricular Hypertrophy

Use multiple voltage-based criteria together when diagnosing LVH on ECG, as no single criterion is clearly superior, and applying the Sokolow-Lyon, Cornell, and Romhilt-Estes criteria in combination maximizes diagnostic accuracy while maintaining high specificity. 1, 2

Primary Voltage Criteria

The three most established and widely validated criteria should form your diagnostic approach:

Sokolow-Lyon Criterion

• SV1 + RV5 or RV6 > 35 mm (3.5 mV) is the most widely used criterion, with specificity of 85-90% but sensitivity typically under 50% 1, 2
• This criterion performs best in patients without bundle branch blocks 3
• In patients with complete left bundle branch block, use a higher threshold of ≥30 mm (3.0 mV) for optimal performance (sensitivity 22.2%, specificity 88.3%) 3

Cornell Voltage Criterion

• SV3 + RaVL > 28 mm in men or > 20 mm in women provides gender-adjusted thresholds with similar 85-90% specificity 1, 2
• The Cornell voltage-duration product (Cornell voltage × QRS duration > 2440 mm·ms) improves diagnostic accuracy 2, 4
• Cornell criteria show better performance in women and may be superior when gender-specific interpretation is needed 1

Romhilt-Estes Point Score System

• This comprehensive scoring system incorporates multiple ECG features beyond voltage 1, 2:
  • QRS amplitude criteria
  • ST-T wave abnormalities (strain pattern)
  • Left axis deviation
  • QRS duration ≥ 0.09 seconds
  • Intrinsicoid deflection time
  • Left atrial enlargement
• Score ≥ 5 points indicates definite LVH with high specificity (85-90%) 1, 5
• Sensitivity ranges from 6-12% but specificity reaches 87-96% 5, 6

Supporting ECG Findings That Increase Diagnostic Confidence

ST-T Wave Abnormalities (Strain Pattern)

• Secondary ST depression and T-wave inversion in lateral leads strongly support LVH diagnosis and indicate more severe hypertrophy with higher cardiovascular risk 2, 4
• These repolarization abnormalities are unusual in simple hypertension among Caucasians but when present suggest advanced disease 4

Left Atrial Enlargement

• P-wave abnormalities suggesting left atrial enlargement may be the earliest ECG sign of hypertensive heart disease, appearing even before voltage criteria are met 2, 4
• This finding increases risk for atrial fibrillation and cardiovascular events 4

QRS Duration Prolongation

• Increased QRS duration or prolonged time from QRS onset to R-wave peak in V5/V6 supports LVH diagnosis 1, 2
• This reflects increased ventricular wall thickness and intramural fibrosis affecting impulse propagation 1

Left Axis Deviation

• May support LVH diagnosis but should never be used as a standalone criterion 2

Critical Factors That Affect Diagnostic Accuracy

Age Considerations

• Standard voltage criteria apply best to adults over 35 years old 1, 2
• QRS voltages decline with increasing age, reducing sensitivity in elderly patients 1
• Diagnosis in patients 16-35 years old, especially trained athletes, has very low accuracy and should be interpreted with extreme caution 1

Gender Differences

• Women have lower upper limits of QRS voltage than men, particularly for SV3 measurements 1, 2
• Always apply gender-specific thresholds when using Cornell criteria 1, 2

Body Habitus

• Obesity paradoxically decreases QRS voltage despite increasing actual left ventricular mass due to increased distance between heart and recording electrodes 1, 2
• This creates false-negative results in obese patients 1

Special Circumstances Requiring Modified Approach

Left Bundle Branch Block (LBBB)

• Generally avoid attempting LVH diagnosis in patients with complete LBBB as standard criteria perform poorly 2, 3
• If diagnosis is necessary, use Sokolow-Lyon with the higher threshold of ≥30 mm 3
• Sensitivity and specificity both deteriorate significantly in LBBB (sensitivity 11.9-95.2%, specificity 6.6-96.6%) 3

Right Bundle Branch Block (RBBB)

• Voltage criteria sensitivity decreases but diagnosis remains possible 2
• Look for: SV1 > 2 mm, RV5/V6 > 15 mm, and QRS axis left of -30° with S wave in lead III 2

Practical Diagnostic Algorithm

1. Measure all three primary voltage criteria (Sokolow-Lyon, Cornell, and Romhilt-Estes score) on every ECG being evaluated for LVH 1, 2

2. Apply gender-specific and age-appropriate thresholds 1, 2

3. If any single criterion is positive, diagnose LVH (high specificity means few false positives) 1

4. Document which specific criteria are met in your interpretation, as different criteria have different prognostic implications 1

5. Search for supporting findings (strain pattern, left atrial enlargement, QRS prolongation) which increase diagnostic confidence and indicate higher cardiovascular risk 2, 4

6. Consider echocardiography for confirmation when clinical suspicion is high but ECG criteria are negative, as ECG sensitivity is only 10-50% 1, 4, 5

Common Pitfalls to Avoid

• Do not rely on a single criterion alone - the overlap between different criteria is poor (only 11.2% of patients positive by Cornell or Sokolow-Lyon are positive by both) 1

• Do not use unvalidated modifications of established criteria - diagnostic accuracy depends on using criteria exactly as tested 1

• Do not diagnose LVH in young athletes based on voltage alone - high false-positive rate in this population 1

• Do not ignore negative ECG in obese patients - obesity reduces voltage despite potentially increased LV mass 1, 2

• Remember that ECG-detected LVH has independent prognostic value beyond just detecting increased ventricular mass - it predicts cardiovascular events and mortality, particularly in patients over 55 years 4